Fast Tracking Combination Prevention at UNAIDS: What is Missing from the Discussion?

November 10, 2015

Position Paper

In late October of 2015, UNAIDS released a new reference document entitled Fast Tracking Combination Prevention: Towards Reducing New HIV Infections to Fewer than 500,000 by 2020 (http://www.unaids.org/en/resources/documents/2015/20151019_JC2766_Fast_tracking_combination_prevention). In the document, UNAIDS advocates for combination prevention, which is a more comprehensive approach to HIV prevention that utilizes all available methods in order to curb new infections. The document’s support to adopt combination prevention is an important step in the right direction in terms of revitalizing national HIV responses, creating more localized and regionalized HIV efforts, and tailoring HIV prevention packages to specific and key populations at risk. The first three components of the six-stage approach proposed in this document are commitment, focus, and synergy. Whereas the last three address implementation, these first three components address strategy and will therefore be the focus of this discussion. Though these components represent positive shifts in the UNAIDS conceptualization of HIV prevention, they are not themselves without serious flaws that will require extensive reconsideration if UNAIDS is to achieve their goal of less than 500,000 new infections by 2020. These flaws include (1) a shift to “top-down” national HIV responses, (2) a cost-effective approach to HIV finances and efforts that threatens to contribute to the scale-down of the global HIV response, and (3) a continued distancing from a human rights approach to HIV prevention and treatment.

The first component that UNAIDS proposes in Fast-Tracking Combination Prevention is “commitment,” conceptualized as a commitment to HIV treatment and prevention working together on a national and international scale. The document stresses that this will be realized by reinvigorated national HIV programs. While fostering strong national programs within ministries of health is certainly a necessary step in creating robust and effective HIV responses, the document makes no mention of the role of civil society or activists in supporting and assisting this revitalization. In fact, what UNAIDS proposes is a completely top-down response to HIV, wherein the national body, or ministry of health, represents the main engine driving both prevention and treatment. This is in stark contrast to how UNAIDS has historically viewed the role of community-based responses. Previously, those living with HIV and those at risk were considered the principal agents through which HIV programs should be realized and directed. National responses were seen as inadequate without the active participation and inclusion of activists and people living with HIV. This shift from grassroots efforts to a mainstream, national-level approach is neither unintentional nor insignificant. In the past decade, UNAIDS has made consistent concessions against the role of activist and civil society groups in order to placate conservative-leaning governments and avoid direct engagement in politics. While the desire to remain separate from political narratives is ostensibly understandable, the fact is that by avoiding direct confrontation of potential political controversies, UNAIDS ironically participates in them. This distancing from civil society exacerbates the social realities and inequalities that perpetuate the epidemic, and only further disenfranchises the very key populations that UNAIDS is supposedly seeking to reach.

The second component of the UNAIDS plan for fast-tracking combination prevention is “focus,” meaning that efforts should be concentrated on key locations, priority populations, and high-impact programs. The argument in this section states that concentrated efforts where there is higher risk for HIV – by population and/or geographic location – will ultimately lead to an overall reduction in HIV transmission compared to evenly distributed prevention efforts. This section of the document addresses important issues, such as the many countries who face limited resources and funding for HIV prevention and the fact that they have different types of epidemics that require tailored responses. In making this argument, however, it is reminiscent of the cost-effectiveness arguments that attacked funding for AIDS treatment after the financial crisis of 2008.[1] The cost-effectiveness argument is ultimately a numerical calculation and lacks a necessary human rights agenda, which is problematic when applied to a UNAIDS strategy. Further, phrases in the document such as “best value for money” make it sound like UNAIDS is anticipating a continued plateau in funding levels or even “scale-down,” versus truly advocating for the financial resources that will be necessary to sustain the scale-up of the global HIV response. By focusing solely on these perceived high-impact programs in key locations and with priority populations, this strategy is bound to leave out other groups of people or what are seen to be lower priority areas, or even reduce funding from some programs that are not deemed “high-impact.” It is possible that statistically and scientifically this strategy makes sense from a technocratic perspective – but it appears to be increasingly detached from the moral and human rights perspective that has been essential for the success of the global HIV response in the past.

The third component, “synergies,” defines program packages for combination prevention tailored towards each at-risk population. The document notes that people at risk of HIV infection have a “cascade” of prevention needs, and as such, the program packages include a combination of biomedical, social, and behavioral components. The document also crucially recognizes the need for strong community empowerment, linkage with critical enablers, and acknowledgement of synergies between structural health and development. All of these points are vital to the global HIV and AIDS response, but the approach – which is methodical and scientifically evaluated – separates the combination prevention approach from its core element: human rights.[2] The document cites the need for people to have the power to make informed decisions about prevention options and to receive support for their choices, but the mere notion of ‘packages’ takes away this autonomy and compartmentalizes people into groups they may or may not fit into. In Mark Heywood’s essay, “Unraveling the Human Rights Response,” Heywood argues that referring to human rights in the context of HIV as the “human rights approach” suggests that there can be a non-human rights approach.[3] The approach the UNAIDS has increasingly been favoring can best be described as a public health approach to HIV, which has the ability to incorporate human rights as it pleases, rather than to be rooted in it. What is actually needed is a form of combination prevention that revolves around the rights of all people at risk, not a series of packages that, no matter how carefully ‘adapted’ for different settings, will never truly reflect the needs of the people they are meant to serve.

No approach to HIV prevention can be absolutely perfect; and with that said, UNAIDS makes a significant move towards endorsing and adopting combination prevention strategies, which is an important step in the right direction, especially at a time when many countries are increasingly relying solely on biomedical approaches rather than strengthening a combination prevention approach. Despite this positive quality, the document also exhibits concerning trends in UNAIDS policy: a top-down tactic towards HIV responses, a resignation to the plateau of HIV financing, and perhaps most alarmingly, further movement away from the cornerstone of human rights that once characterized UNAIDS approaches. In moving forward, it would be best for UNAIDS to look back at their own efforts that championed the incorporation of civil society and the significance of human rights.